HEALTH - UNHCR

Improve access to comprehensive primary healthcare (PHC).
Improve access to hospital (including emergency room care) and advanced referral care (including advanced diagnostic laboratory and radiology care)
LEAD MINISTRY Ministry of Public Health (MoPH) Dr. Rasha Hamra rashahamra@yahoo.com
COORDINATING AGENCIES WHO
1,365,000 1,365,000
1,500,000 1,062,681
Female Male
552,594 510,087
701,610 663,390
14,349 13,351
% of displaced Syrians, vulnerable Lebanese, Palestine Refugees from Syria (PRS) and Palestine Refugees in Lebanon (PRL) accessing primary healthcare services. %e of vaccination coverage among children under 5 residing in Lebanon.
Indicators % of displaced Syrians, Lebanese, PRS and PRL admitted for hospitalization per year.
Improve outbreak control and infectious diseases control.
Outcome #3
Indicators # of functional early warning and surveillance system (EWARS) centres.
Indicators Prevalence of behavioural risk factors and protective factors in 10 key areas among young people aged 13 to 17 years.
1 The response plan is designed to contribute significantly to gender equality.
117,000 20,000 9,920 10,080
NEEDS-BASED APPEAL 325.5 million$
PART II : OPERATIONAL RESPONSE PLANS - HealthLEBANON CRISIS RESPONSE PLAN 2017-2021
and tertiary physical and mental health care system; effective outbreak and infectious diseases control; and increased access to adolescent and youth health programmes. These systems and programmes should be supported by accessible and good quality national data to inform monitoring of the situation and decision making. Data systems are available at the PHC and hospital care levels and are linked to the epidemiology surveillance unit under the Ministry of Public Health. The Health sector will extend its support in 2021 to enhance data collection and analysis, aiming for improved evidence-based programming. Using the national health system, these coordinated interventions aim to increase the equitable access to quality primary and hospital care of displaced Syrian and non-Syrian populations, including non-sponsored migrant workers, vulnerable Lebanese individuals, and Palestinian refugees from Syria and Lebanon. Additionally, excess mortality, morbidity, and disability, especially in poor and marginalized populations, will be reduced; healthy lifestyles will be promoted, with a highlight on smoking cessation; and risk factors to human health that arise from environmental, economic, social, and behavioural causes will be reduced. Health systems that equitably improve physical and mental health and nutrition outcomes and respond to people’s legitimate demands will be promoted and financially fair. In addition, national policies will be framed; an institutional environment for the Health sector will be reinforced; and an effective health dimension to social, economic, environmental, and development pillars will be promoted.
Based on lessons learned during the implementation of the LCRP 2017–2020, the Health sector will keep on committing to align its areas of work in 2021 with the Sustainable Development Goals (SDGs), in particular SDG 35 with a focus on universal health coverage. The Ministry of Public Health response strategy,6 drafted in 2015 and updated in 2016, serves as the guiding document for the LCRP Health sector.ii Activities under the LCRP fall within the scope of this strategy, starting from community outreach, awareness, and preventive activities to curative and referral services. By 2021 the strategy aims for the progressive expansion and integration of these services in the existing national health care system, in an effort towards universal health coverage.
The Health sector will continue its work to strengthen planning and coordination by reinforcing the existing coordination mechanisms, which are essential to ensuring a harmonized response and prioritization of services. The sector will also maintain close coordination and communication with the response mechanisms in place for the COVID-19 outbreak and the Beirut Port explosions. Strengthened planning and coordination will enable a more efficient and effective delivery of services, which is particularly important when considering the (5) SDG3: “Ensure healthy lives and promote well-being for all at all ages.” (6) The Ministry of Public Health Response Strategy serves four strategic objectives: increase access to health care services to reach as many displaced persons and host communities as possible, prioritizing the most vulnerable; strengthen health care institutions and enable them to withstand the pressure caused by the increased demand on services and the scarcity of resources; ensure health security, including a strengthened surveillance system for the control of infectious diseases and outbreaks; and Improve child survival rates.
Overall Sector Strategy After a decade of responding to the health needs of displaced Syrians, vulnerable Lebanese, and Palestinian refugees from Syria and Lebanon, in 2020 the Health sector was faced with an unprecedented crisis, which started late in 2019 with country-wide protests and a deteriorating socioeconomic situation. The economic and financial crisis has hindered the access of vulnerable populations to health services from both the supply and demand sides. The 2019 novel coronavirus (COVID-19) outbreak1 further hampered the access for both vulnerable Lebanese and displaced individuals to needed primary health care2 and hospital care. At the beginning of August 2020, the devastating Beirut Port explosions3 topped off the exceptional situation and hindered access to physical and mental health care services even further not only in Beirut and Mount Lebanon but across the country. In the blast area, around 27 primary health care (PHC) facilities became non- functional, three major hospitals had to close, and three more had to reduce their capacity. In some facilities, COVID-19 preventive measures were not being adhered to.i The medical supplies were depleted in all health facilities, especially first aid and trauma kits. Outside the blast area the PHC facilities and the hospitals were faced with an increased demand, which put them under pressure given the already compromised capacity in terms of human resources and equipment as affected population sought care.
Considering the unique situation, the Health sector under the Lebanon Crisis Response Plan (LCRP) remains committed in 2021 to supporting an equitable continuation of quality physical and mental health care services for displaced Syrians, vulnerable Lebanese individuals, Palestinian Refugees from Syria, and Palestinian Refugees from Lebanon through the national health system. Displaced non-Syrians,4 including undocumented migrant workers, will benefit from the support offered by the Health sector’s partners on a non- discriminatory basis.
The Health sector’s theory of change is based on the premise that the removal of access barriers for the underserved, vulnerable, and marginalized groups through safe, dignified, accountable, and inclusive health and nutrition service provision will require coordinated interventions in different areas: a strong comprehensive and complementary primary, secondary, (1) The response to the outbreak, considered a Public Health Emergency of an International Concern (PHEIC), was implemented following the eight universal pillars: country-level coordination, planning, and monitoring; risk communication and community engagement; surveillance, rapid-response teams, and case investigation; points of entry, national laboratories; infection prevention and control; case management; and operations support and logistics. (2) Primary health care includes services such as: vaccination, medication for acute and chronic conditions, non-communicable disease care, sexual and reproductive health care, malnutrition screening and management, mental health care, dental care, basic laboratory and diagnostics, as well as health promotion. (3) On 4 August 2020 a large amount of ammonium nitrate stored at the port of the city of Beirut, the capital of Lebanon, exploded, causing at least 203 deaths, 6,500 injuries, and US$15 billion in property damages, leaving an estimated 300,000 people homeless. The response to the explosions was planned in line with both the COVID-19 action plan and the existing Health sector strategy, which aims to ensure equitable and sustainable access to quality physical and mental health care services for the vulnerable population in Lebanon. (4) Displaced populations from other nationalities include people from Bangladesh, Egypt, Eritrea, Ethiopia, Iran, Iraq, Jordan, Nigeria, Sudan, and Yemen.
LEBANON CRISIS RESPONSE PLAN 2017-2021 PART II : OPERATIONAL RESPONSE PLANS - Health
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multifactorial nature of the ongoing crisis. Regular meetings, guidance development, information dissemination, consistent reporting, contingency indicators monitoring, and situation analysis will be maintained and reinforced to ensure a delicate and fluid coordination between the various forums,7 avoid duplication, identify gaps in service provision, and advise on programme designs accordingly.
The Health sector’s main priority will continue to be to shift the health response towards investments in strengthening the public health system and enhancing institutional resilience to sustain the provision and quality of services in order to achieve a positive and sustainable impact on health indicators for the medium and long terms. Direct service delivery components of the strategy will also be maintained to cover critical short-term needs for vulnerable people. In 2021 the sector will coordinate with the Immediate Response Model8 and the national task force that it is working towards the development of a national unified long- term PHC subsidization protocol. The unified financial model will help to reduce out-of-pocket expenditure in a sustainable long-term approach that will enhance the resilience of the Health sector. Health partners will be encouraged to implement this model in the supported centres and to continue exploring in detail ways to further optimize the package of services offered (including financing mechanisms) to ensure an effective, cost-efficient and sustainable response. Health partners will additionally work to conduct an outcome and return on investment evaluation to measure the efficiency of the implemented activities. The sector will continue the work to strengthen the national health system by carrying out the interrelated health system functions of human resources, finance, governance, capacity- building, information, medical products (including personal protective equipment), vaccines, and data technologies. Because of variations among geographical areas, populations and facilities, the sector supports that decisions are made at all government levels (national, provincial, district, and regional) to empower decentralized decision-making and to encourage greater, more efficient and more homogenous delivery of health services. Given the large increase in demand for public services, the Health sector will explore innovative ways to engage with the private sector at the primary, secondary, and tertiary health care level. This will allow the public system to withstand the pressure caused by the increased demand and scarcity of resources.
The Health sector will also ensure that mental health
(7) Lebanon Crisis Response Plan; Beirut Port explosions; COVID-19 outbreak; and the Reform, Recovery, and Reconstruction Framework for Lebanon. (8) The primary health care department developed the Immediate Response Model (IRM) to coordinate the Beirut blast response and ensure the subsidization of a standardized package of services across all primary health care centres supported by national and international non-governmental organizations. The IRM is a temporary model that delineates the protocols of subsidizing primary care service packages and provider payment mechanisms. The IRM is to be implemented for three months in the area affected by the blast, while a more advanced long-term primary health care subsidization protocol is prepared and fine- tuned with the aim to be applied in a uniform way throughout the Ministry of Public Health’s primary health care centres network. For this purpose, a joint national taskforce composed of the Ministry of Public Health primary health care department, relevant donors, United Nations agencies, and national and international non-governmental organizations was created.
services are improved across Lebanon while having as an immediate priority the need to increase access to quality and evidence-based mental health services, including psychotropic medications9 at three levels: 1) the PHC level, through trained and supervised staff as part of the subsidized packages; 2) the community-based level, through a multidisciplinary specialized team; and 3) the hospital level, through the establishment of psychiatry wards. The sector will additionally work to enhance key nutrition interventions, including skilled breastfeeding counselling, detection and management of all forms of malnutrition, and the provision of recommended micronutrient supplementation. To face the lack of up-to-date data on nutrition and the different forms of malnutrition, the sector will support a series of multisectoral assessments.10 It will also actively contribute to the setting up and implementation of a multisectoral nutrition action plan and will support existing nutrition policies and surveys.
The sector will ensure that COVID-19 preventive measures are mainstreamed throughout all activities, including the safety of both health care workers and targeted populations.
Considering the economic situation, the increasing tensions between population groups around the issue of access to services, and the increasing poverty in the country, the Health sector will focus on balancing its targeting across all population groups, including displaced Syrians, and will increase its contribution to the Lebanese host community. Additionally, in an increased effort to mitigate social tensions, non-Syrian displaced populations, including non-sponsored migrant workers, will indirectly benefit from an increased access to primary and hospital care services offered by the sector’s partners. Health programmes will be designed and planned to target the most vulnerable from all population cohorts based on a non-discriminatory approach, and therefore displaced population from different nationalities will benefit from the health activities offered under the LCRP following a targeting and prioritizing mechanism.11 The sector will work to enhance referral mechanisms and to ensure equitable access to quality physical and mental health care to vulnerable populations, while prioritizing the most marginalized groups 12 and taking into consideration the gender balance and emerging needs (such as mental health and nutrition) of the most vulnerable populations, including infants, pregnant women, lactating mothers, adolescent girls, and older people.
In 2021 additional attention will be placed on strengthening the Health sector’s commitment to mainstreaming protection through its interventions, reducing barriers for affected persons in accessing (9) In line with the National Guide for Rational Prescription of Medication for priority mental health and neurological conditions. (10) Assessments include a survey including anthropometric measurements; anaemia screening; and knowledge, practices, and attitudes on maternal, infant, and young child feeding. (11) The targeting and prioritization mechanism for the Heath sector are decided by every partner in coordination with the sector based on the programme and objectives. (12) Marginalized groups include out-of-school, street, and working children, adolescents, and youth.
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health services, improving accountability, and improving the quality of health care services. Particular attention will be paid to improving the responsiveness of complaint and feedback mechanisms within the primary health care centres; strengthening referrals of affected persons between PHC and other service providers; improving the use of data collected through referral and complaint and feedback channels to inform organizational learning; and promoting the adaption of the Vulnerability Assessment of Syrian Refugees in Lebanon and other surveys. Steps will also be taken to promote the inclusion of persons with disability and older persons13 through their greater participation in needs assessments, disaggregated reporting, and adapted information provision and infrastructure. In this respect, specific efforts will also be made to adapt information materials and health awareness campaigns to reach working and street children to promote their access to health services. The sector will closely work with the Protection, Sexual and Gender-Based Violence, and Child Protection sectors to identify and respond to the needs of the target population and to mitigate protection risks associated with health activities, namely the access of undocumented individuals to health care and the retention of bodies and the confiscation of personal identification documents by hospitals.14 Special attention will be paid to health interventions children under five years of age, pregnant and lactating women, adolescents (including adolescent girls married before the age of 18), youth, persons with disabilities, older persons, survivors of gender-based violence, persons living with HIV/AIDS, persons facing gender-based discrimination and other vulnerable groups. To assess challenges around access to health services, people of all ages and both genders will be equally consulted. Access to information on services and primary health care in general will be regularly monitored through consultations, assessments, and other forms of engagement, as well as through existing complaint systems.
The Health sector will increase its contribution in 2021 to strengthen public health knowledge and evidence- based practices implemented by sector partners. For this, the sector has established a research committee15 with the objectives of decreasing duplication of assessments, channelling available research resources to the gap in information and not merely to academic interest, and ensuring ethical considerations are accounted for when the assessments or research target displaced populations and vulnerable communities. This LCRP health research committee will review planned assessments for justification and indications, methodology, ethical principles, and coordination with existing or planned assessments; and will review proposed research relating (13) Older people were particularly affected by the blast and they continue to be a relatively high percentage of the population in the affected area. According to the assessment results of the Beirut port explosions by the Lebanese Red Cross, 57 per cent of people surveyed were aged 18–60 years (n=12,072), 24 per cent were over 60 years (n=5,038), and the remaining 19 per cent were under 18 years old (n=3,978). See https://reliefweb.int/sites/reliefweb.int/ files/resources/dm-rp-msna-dana-200825.pdf. (14) Hospitals implement such practices to pressure the patient to pay required fees. (15) The research committee is composed by members nominated and selected with the possibility of rotational membership. Members are composed of the Ministry of Public Health, United Nations agencies, and international and national non-governmental organizations from the Health core working group.
to health among displaced and vulnerable populations and ensure that agreed criteria are met.
Sector results: LCRP impacts and sector outcomes, outputs, and indicators The Health sector has identified four main outcomes for the sector strategy in 2021 and its direct contributions to Impact 3: “Vulnerable populations have equitable access to basic services through national systems.” These outcomes are based on the sector’s analysis of the protective environment, taking into account the different challenges faced by age, gender, and diversity groups in accessing health services. The sector’s approach to the delivery of equitable services is strongly rooted in a vulnerability and rights-based approach to programming. Outputs and activities under each outcome of the strategy are designed to ensure that different groups have equitable access to affordable, essential, and high-quality prevention, promotion, treatment, and care services.
Expected results Outcome 1: Improve access to comprehensive primary health care (PHC)
Strengthening the health system remains a key priority in 2021 in light of the increasing demand on services and scarcity of resources. This will ensure greater geographical coverage and accessibility, including for people with disabilities, to quality primary and inclusive health care services. Under this outcome, it is assumed there will be an increased need for primary health care and that health partners will continue to provide support to the Ministry of Public Health’s PHC network, which provides equitable and affordable access to quality health services.
Output 1.1: Financial subsidies and health promotion provided to targeted population for improved access to a comprehensive primary health care package
The Health sector aims to support equitable access to comprehensive16 quality primary health care to displaced Syrian and non-Syrian individuals (whether registered or non-registered as refugees by UNHCR) and vulnerable Lebanese, primarily through the Ministry of Public Health’s network of PHC centres and dispensaries (including the Ministry of Social Affair’s social development centres in instances where there is uneven geographical coverage, or where the caseload is too heavy for the network to bear).17 A specific focus will be to increase mental health and nutrition awareness and services to account for the increasing needs. Displaced non- Syrians will benefit from the PHC support offered by partners on a non-discriminatory basis. Support to the comprehensive PHC package in 2021 will take into consideration preventive measures to cope with the
(16) Comprehensive primary health care is inclusive of vaccination, medication for acute and chronic conditions, non-communicable disease care, sexual and reproductive health, malnutrition screening and management, mental health, disability services, dental care, as well as health promotion. (17) Palestinian refugees from Syria and Lebanon are an exception as their access to primary health care is through UNRWA clinics.
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COVID-19 situation. Key elements under this output include:
• Prioritize comprehensive financial support: An improved comprehensive financial support will be provided to displaced Syrian and vulnerable Lebanese individuals, Palestinian refugees from Syria, and Palestinian refugees from Lebanon who are unable to access health services due to their economic conditions. Non-Syrian displaced populations, including non-sponsored migrant workers, will benefit from increased access to primary and hospital care services offered by sector partners based on a non-discriminatory approach. Health partners will continue to support better access by reducing cost-related barriers, such as doctor’s fees, additional treatment, and transportation expenses through complementary programme activities. Partners will provide additional focus to ensure a balanced targeting among population cohorts and to increase targeting to vulnerable Lebanese individuals, considering the ongoing crisis and financial hardship. The sector’s partners will be encouraged do adopt the long-term primary health care subsidization protocol18 that is elaborated by the national taskforce and that should be implemented in all PHC centres. This will be closely monitored in 2021 to identify best practices that can be further developed and expanded to ensure better health outcomes over the long term.
• Use of mobile medical units on exceptional basis: The Health sector will aim to provide PHC services through mobile medical units only on exceptional basis. In areas where there is no primary health care coverage and in security-related and emergency situations, activities such as vaccination campaigns, outbreak investigation and response, and the provision of PHC will be provided through mobile medical units linked to the closest fixed PHC centre. While implemented in-line and in collaboration with existing national structures/mechanisms, this will allow the sector to contain outbreaks and to increase access to PHC services in case of a deteriorated situation. Consequently, this will contribute to decreasing morbidity and mortality rates. While using mobile medical units when necessary, the sector will at the same time ensure that access to primary PHC centres is promoted and restored as soon as possible.
• Strengthen health promotion and community outreach: The Health sector will strengthen facility- based health promotion and community outreach activities on various health topics (e.g., vaccination, pregnancy care, family planning, communicable and non-communicable diseases, mental health, COVID-19 prevention, etc.). Considering the increased needs across all population groups, the sector will support a scale up of awareness-raising activities related to recommended infant and young
(18) See note 8.
child feeding practices, optimal nutrition, and malnutrition detection management and prevention. The availability of skilled breastfeeding counselling services will be ensured in the PHC centres. Efforts will aim at increasing awareness on the availability and acceptability and therefore accessibility of services (including nutrition, mental health, and gender-based violence services) at the facility and community level. This will always be conducted through making updated information available to the population in need, including service mapping, both online and in printed health brochures, with targeted and relevant health information. The use of media will also be considered for a broader communication when needed given the role that the media can play in promoting healthy lifestyles. Health partners will harmonize health messages and target women and men within communities to influence decision-making and ensure an environment that is supportive of positive health-seeking behaviours. Awareness-raising will also include the development and design of information packages and employing various dissemination methods, in consultation with affected communities to ensure that the materials are appropriate and accessible to all groups, including people with specific needs and older persons. Where possible, intersectoral linkages will be made to maximize health education dissemination channels including through education facilities and after-school accelerated learning programmes for children who work, and through the Protection and Child Protection sectors for the dissemination of health related messages and information in women’s and girl’s safe spaces, community centres and child-friendly spaces. The sector will also expand its support to the Ministry of Education and Higher Education to strengthen COVID-19 preventive measures in schools. The provision of information and education along with addressing other accessibility barriers will contribute to decreasing social stigma and increasing demand for primary health care. Consequently, health promotion will increase equitable access to quality PHC, including increased demand for preventive care; and thus, help to avoid preventable medical complications.
• Strengthen complaint and feedback mechanisms: Fifty out of 242 Ministry of Public Health’s PHC centres have active complaint and feedback mechanisms to ensure patients can report any challenges. The mechanisms are accessible for all groups, including people with disabilities, older people and youth, and the data is recorded and managed confidentially. In addition, information on the Ministry’s 24/7 hotline, which displaced populations can call for feedback and complaints, is circulated on a regular basis. The Ministry of Public Health uses all possible resources to respond to all complaints; however, additional support from the Health sector is still needed to strengthen and expand the current feedback mechanismiii and to collect and analyse
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data. Supporting the complaint and feedback mechanism will improve the service delivery and the accountability for affected populations, enhance public trust, and inform the design of the programmes – thus, increasing demand for and access to primary health care, including mental health services. In 2021 the sector will support the roll out of a hotline to request infant and young child feeding support, and will report violations of Law 47/2008 regarding breastfeeding protection and the promotion and aggressive marketing of breastmilk substitutes.
The target for 2021 is 4,950,763 subsidized or free consultations provided at the PHC level to displaced Syrian and vulnerable Lebanese individuals and Palestinian refugees from Syria and Lebanon. Consultation monitoring will be disaggregated by age and sex to allow for gender analysis of potential barriers to PHC access that need to be addressed. To improve access of the vulnerable population to mental health, 5 per cent of the population in need will be targeted, and monitoring of mental health consultations will be disaggregated by population cohort, age, and gender. To monitor malnutrition among children under five, 30 per cent of the total number of children in need will be screened, and the actual numbers will be monitored through clinic-based growth monitoring screenings for acute malnutrition data.
Output 1.2 - Free of charge chronic disease medication provided at primary health care centre level
The Health sector will continue to advocate for the timely procurement of quality chronic disease medications and the equitable distribution to the population in need. Health partners will support the Ministry of Public Health to accurately estimate the medication needs based on utilization, co-morbidity data, and previous stock interruptions. The provision of chronic disease medications free of charge will contribute to enhancing the quality of life for persons with chronic diseases, increase financial access to primary health care, decrease the burden on secondary health care, and reduce the high cost of hospitalization resulting from poorly controlled chronic medical conditions. Consequently, it will also decrease the morbidity and mortality rates. Institutional support and health system strengthening initiatives, such as training on medication and stock management, remain key to improving the existing health network. Improved supply chain management remains essential since even when funds are available medications should be distributed in a timely and consistent way. This includes electronic health records, electronic stock inventory, and data-driven decision- making to maximize the efficient use of resources. By investing in supply chain management, the efficiency of the system will increase when the supply of medications will be available.
In 2021 the Health sector will target 230,000 individuals
who are enrolled in the national chronic disease medications programme at the Ministry of Public Health. This includes 172,500 Lebanese and 41,400 displaced Syrian individuals, 9,177 Palestinian refugees from Syria and 6,923 Palestinian refugees from Lebanon, all of whom are receiving chronic medication free of charge through UNRWA clinics. The sector will be flexible to target additional 10 to 15 per cent of vulnerable Lebanese given the current deteriorated economic situation.
Output 1.3: Free acute disease medication, medical supplies, and reproductive health commodities provided at the PHC centre level
The Health sector will support the Ministry of Public Health in the provision of acute disease medications free of charge, as well as medical supplies and reproductive health commodities for displaced Syrian and vulnerable Lebanese individuals while taking into consideration the current chronic disease medications shortage.19 Displaced non-Syrians will also benefit from the primary health care support offered by partners on a non- discriminatory basis. Increasing support for the growing number of vulnerable Lebanese individuals will be key in 2021, given the deteriorating economic situation and the potential subsidies withdrawal. Another focus will be extending support to an efficient and timely supply chain management. The sector will continue to advocate for funding and will aim at aligning the list of acute disease medications with the treatment protocol. Health partners will closely coordinate to accurately estimate the needs and support in the procurement of acute disease medications as well as other medical commodities. This support will lead to increased availability of supplies, decreased financial barriers and support for greater access to primary health care. Furthermore, the free provision of acute disease medication contributes to an enhanced preventive programming, thus decreasing the risk of complications and the need for hospital care. Without timely access to quality acute disease medications, medical supplies – including personal protective equipment and reproductive health commodities – the risk of COVID-19 infection and preventable hospitalization will increase in Lebanon, which will increase the financial burden and negatively impact health indicators, especially for morbidity and mortality rates, including neonatal and maternal mortality. The sector will aim to ensure that the current mechanisms of national drug procurement for acute disease medications, medical supplies, and reproductive health commodities (including family planning commodities and post-exposure prophylaxis kits) are aligned with the existing needs of vulnerable Lebanese and displaced Syrian individuals, as well as other population groups, and should avoid any duplication for parallel procurement mechanisms by health partners.
(19) Procurement of personal protective equipment and infection, prevention, and control kits for the prevention of COVID-19, as well as trauma and first aid kits as a response to the Beirut Port explosions, will be ensured through the stand-alone respective emergency responses.
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In 2021 the Health sector will increase its target to some 2.4 million displaced Syrian and vulnerable Lebanese individuals within the existing primary health care channels, as well as to 47,700 Palestinian refugees from Syria and Palestinian refugees from Lebanon through UNRWA clinics.
Output 1.4: Free routine vaccination provided for all children under five at the PHC centre level and through vaccination campaigns
Due to the multiple crises in 2020, the number of children under five receiving their routine vaccination was reported to be below the annual average. In 2021 the Health sector aims to support the Ministry of Public Health to achieve 100 per cent vaccination coverage of displaced Syrian children, Palestinian refugee children from Syria and Lebanon, and vulnerable Lebanese children,20 based on the national vaccination calendar. This requires the enforcement of the Ministry of Public Health’s policy related to the provision of free vaccination at the primary health care level as well as the expansion/acceleration of routine vaccination activities with a focus on low vaccination coverage areas21 and the improvement of the cold chain and supply systems. Outreach activities related to vaccination will be coupled with malnutrition screenings under Output 1.3, and referrals, if needed, to maximise impact of outreach efforts. This will be done through increased awareness on the availability of free vaccination services coupled with infection, prevention, and control measures at PHC centres, and by supporting the Ministry of Public Health to increase its COVID-19 prevention activities and its internal monitoring, especially when the patient is being charged for vaccination. Vigilance is required to ensure that Lebanon remains Polio free, and to contain any possible outbreak. To this end, a national measles campaign, initiated in 2019, was expanded through 2020 to ensure the interruption of the disease transmission and to allow Lebanon to accelerate its progress towards the elimination of measles. Despite multiple challenges,22 the Ministry of Public Health launched the second phase of the measles campaign on 14 October 2020 with the aim of targeting all the remaining Lebanese cadastres. Advocacy to endorse legislation on free vaccination in PHC centres remains key to ensure greater vaccination coverage and to prevent further outbreaks. In addition, a more systematic vaccination process needs to be developed and endorsed for official return activities. The efforts of the Health sector to ensure that free vaccination is provided for all children under five will positively impact the vaccination status of the children in Lebanon, prevent vaccine preventable diseases and consequently decrease morbidity and mortality.
In 2021 the sector is targeting 482,000 children under
(20) It is estimated that 50 per cent of vulnerable Lebanese children receive vaccination through the public health system, while the remaining 50 per cent receive vaccination through private health systems. (21) Results of the annual WHO Expanded Programme on Immunization coverage cluster survey. (22) The main challenges are represented by acceptance, lockdown and mobility, and fear of COVID-19 infection.
five23 to receive routine vaccinations to be distributed among displaced Syrians, vulnerable Lebanese, and Palestinian refugees from Syria and Lebanon at the PHC level.
Output 1.5: Free COVID-19 vaccine provided to priority groups
Lebanon has officially requested to reserve COVID-19 vaccine doses for 20 per cent of the resident population from all population cohorts, including displaced individuals. Due to the high cost of the vaccine doses24 and to the ongoing economic crisis, the support of the international community will be needed to help the Government of Lebanon procure the needed quantities, identify the priority groups,25iv and implement an efficient vaccination programme accordingly. Support to strengthen the national cold chain management system and vaccine logistics remains key for the provision of quality vaccination services.
The 20 per cent target is equivalent to around 1,115,000 individuals segregated by nationality.
Output 1.6: Primary health care institutions’ service delivery supported
The expansion of the Ministry of Public Health’s network of PHC centres to up to 250 centres distributed equitably across Lebanon and the enhancement of the quality of services and the physical structure will all strengthen the capacity of the Ministry to respond to the PHC needs of displaced Syrians and vulnerable Lebanese. Moreover, support across most primary health care centres is required in terms of increasing human resources, as they are understaffed and overloaded. By providing staffing support, the Health sector will contribute to enhancing central data collection and analysis, to decreasing the workload at the facility level, and to increasing the ministerial capacity to respond to increased demand.
Nevertheless, the sector needs to identify and prioritize support for essential staff whose services are critical over the long run, which will allow the Ministry to retain trained and qualified personnel. Health partners will continue providing equipment, including personal protective equipment and infection, prevention, and control kits not only to respond to current needs, but also to replace old and deteriorating equipment. This will allow the centres to deliver quality services and to expand the current coverage, which increases availability and therefore enhances access to primary health care services for vulnerable groups. Additionally, the sector will aim to build the capacity of staff through ongoing training, coaching, and supervision according to identified gaps. These trainings will include modules
(23) Based on the LCRP population package for 2021, children under five are 5.5 per cent of the Lebanese population, 16.7 per cent of the displaced Syrian population, and 9.7 per cent of the Palestinian population. (24) It is estimated that one vaccine dose costs around $10.55 as ex-factory price, with an expected two-dose regimen per person. (25) Based on the Fair Allocation Framework for COVID-19 the three groups of people as highest risk who should get priority access to COVID-19 vaccines are frontline health and social care workers, people over the age of 65, and people under 65 who have underlying health conditions.
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on soft skills,26 safe identification and referral of survivors of sexual and gender-based violence, and survivor- centred approaches – all with a focus on respecting confidentiality and non-discrimination. In 2021 the sector will support the roll out of a training led by the Ministry of Public Health on infant and young child feeding, counselling, and standard operating procedurev to improve knowledge and address inadequate practices related to inadequate breastfeeding initiation and the separation of mother and baby at birth. Trainings will target midwives, but also paediatricians, gynaecologists, and infectious diseases specialists, among others. Building the capacity of health care providers will lead to enhanced quality of service provision and therefore to increased trust towards the public services, which will in turn positively impact the access of vulnerable groups to PHC services. Notably, the sector will encourage an equal ratio of female/male staff to be trained.27 It will also focus on capacity-building as well as monitoring key quality indicators for improved quality of care through increased coordination between partners and the use of common tools.
The sector will support the Ministry of Public Health to strengthen its accreditation programme28 and internal monitoring and evaluation measures at the primary health care level. It will particularly focus on compliance with the national health strategy, especially in relation to harmonized costs for services on the basis of the unified model under elaboration by the national health taskforce, and on ensuring free immunization services at all centres – especially in relation to a unified costing system, including the provision of free vaccination.
Additionally, the Health sector will explore ways to support the expansion of the existing health information system. Electronic patient files for beneficiaries were established, along with a medication electronic monitoring system,29 in 13 PHC centres. The data collected through the centres will be further expanded and strengthened to ensure harmonized reporting through common tools and indicators as well as on the quality of service provision, including relevance, accuracy, completeness, and timeliness. This will lead to more regular access to data, which will help to inform future health care priorities. The nutrition surveillance system will be strengthened and used to inform nutrition programming. In addition, a multisectoral nutrition assessment will be conducted, including a survey to identify the prevalence of acute and chronic malnutrition and anaemia. This survey will be used as a basis to scale up nutrition programming.
The sector aims to target all the primary health care centres in 2021 within the Ministry of Public Health’s network.
(26) As an example, the Clinical Management of Rape Training targeting health staff includes a module on soft skills (27) It is observed that more female health staff attend trainings compared to male health staff, which is reflective of the general health workforce. (28) In 2008 the Ministry of Public Health initiated work on an accreditation mechanism for primary health care centres aiming to include all network centres to monitor and ensure quality. The accreditation programme is fully funded by the Ministry of Public Health and is implemented by the primary health care department (29) PHENICs: a health information system to link and unify the network of primary health care centres.
Risks associated with the outputs under Outcome 1 range from the lack of available funds to ensure timely and quality subsidized PHC services to the non-compliance of PHC centres with the instructions provided by the Ministry of Public Health, regarding hidden costs.30 This may result in decreased access to PHC services and could increase demand for complicated secondary health care. Therefore, vulnerable populations face challenges to access needed health care, which will jeopardize their health status and put them at risk of health complications. In addition, financial hardship will increase and national health indicators, including morbidity and mortality, will be negatively affected. Efforts from health partners are needed to advocate for funding in order to support strengthening the health services for the growing number of vulnerable populations, given the ongoing multiple crisis. Partners need also to maintain and expand support to the Ministry of Public Health in order to improve internal monitoring and evaluation measures. With time, and as the Ministry’s capacities are strengthened, the institutional support is expected to progressively decrease.
Outcome 2: Improve access to hospital (including Emergency Room care) and advanced referral care (including advanced diagnostic laboratory and radiology care)
The sector aims to provide hospital care to 12 per cent of each population group. In addition, through health partners, in 2021 the sector will encourage and support hospitals to join the World Health Organization’s baby- friendly hospital initiativevi and to follow the national nutrition guidelines for pregnant women with COVID-19.vii
Output 2.1: Financial support provided to targeted population for improved access to hospital and advanced referral care
The Health sector aims to ensure access to hospital and specialized referral care for all displaced Syrian individuals (whether registered or non-registered as refugees by UNHCR), Palestinian refugees from Syria, and Palestinian refugees from Lebanon in need of hospital care.31 Health partners will continue to provide financial support to targeted populations through the implementation of cost-sharing mechanisms. The main activity under this output is the provision of financial support to access hospital services. This is currently done primarily through the UNHCR referral care programme,viii which covers 75–90 per cent of the hospital bill and targets displaced Syrian and non-Syrian individuals,32 as well as through UNRWA’s hospitalization policy for (30) Examples of hidden costs are a charge for opening a file and a consultation fees prior to providing free vaccination. (31) This includes advanced diagnostics, laboratory tests and radiology (on an outpatient basis), and admission to hospital, including Emergency Room care. (32) As of July 2018, changes were implemented in relation to the Referral Secondary Healthcare Programme to reduce the overall cost of the referral care programme, to increase protection for beneficiaries whose patient shares are substantially high, and to simplify and improve the efficiency of the process. The new cost-sharing mechanism requires displaced Syrians to first contribute $100, with the remaining 75 per cent of the cost being covered. Nevertheless, beneficiaries never pay more than $800. In 2020, given the decreased capacities to pay patient shares, the referral secondary health care programme (updated in 2018) was revised to reduce financial hardships for both displaced populations and hospitals. The revised cost-sharing scheme was implemented for a limited time period (five months) and will probably not be extended beyond 2020.
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Palestinian refugees from Syria and Palestinian refugees from Lebanon. In complementary manner, health partners will continue to provide financial support to cover 10–25 per cent of the patient’s share based on a prioritization approach specified by every partner in consultation with the Health sector. Partners will also aim to cover those conditions that fall outside of UNHCR or UNRWA hospitalization schemes.
Given the ongoing crisis and the growing number of vulnerable Lebanese, health partners in 2021 will aim to add vulnerable uninsured Lebanese individuals as a new target in a cost-sharing scheme mechanism that includes public and private hospitals for those covered by the Ministry of Public Health as a last resort. Health partners will also aim to cover the patient share for vulnerable Lebanese individuals after being admitted and supported by the Ministry of Public Health. Partners will on exceptional basis and following a prioritization approach cover uninsured Lebanese patients who fall outside the coverage criteria of the Ministry of Public Health. The sector will consider public communication channels to inform the Lebanese population about the hospital care support programmes.
A national taskforce will be established to develop a unified model for the subsidization of hospital care for the vulnerable population where the mechanism put in place is well defined and coordinated among relevant stakeholders, including the Ministry of Public Health. This will help in identifying coverage criteria and avoiding duplication, and therefore support donors in financing the new target group of vulnerable population to access hospital care.
The financial support provided helps to decrease mortality rates and enhances the quality of life. In addition, it will contribute to enhancing neonatal and maternal health by supporting hospital-based deliveries and neonatal services. Social tension will also be mitigated through the balanced targeting approach. Considering the high cost of hospital care services in Lebanon and the increasing economic vulnerabilities across all populations, health partners need financial resources to maintain the current levels of financial support provided. Additional resources are also needed to expand the support to medical conditions that do not fall under the current schemes, and to support hospitalization for mental health conditions given the increased needs and scarce resources in terms of financials and hospitals capacity.33
In 2021 the sector will target 105,553 displaced Syrian individuals,34 123,580 Lebanese individuals,35 3,324
(33) Considering the COVID-19 situation, some hospitals shifted the beds dedicated to mental health towards COVID-19 treatment. (34) This figure is based on the number of displaced Syrians registered by UNHCR as refugees, equivalent to 879,529 (as of end of September 2020). It is important to note, however, that all displaced Syrians (estimated by the Government of Lebanon at 1.5 million), whether registered or non-registered with UNHCR as refugees, are eligible for hospital coverage according to UNHCR Standard Operating Procedures for Referral Care. (35) The Health sector target is 50 per cent of the Lebanese population in need. Estimates reveal that more than 55 per cent of the country’s population is now trapped in poverty and struggling for bare necessities and that more than half of the Lebanese population (53.3 per cent) is not covered by any form of health insurance. The number is calculated based on the assumption that 12 per cent of the uninsured population will need access to hospital care (half of which is targeted in the LCRP).
Palestinian refugees from Syria and 2,400 Palestinian refugees from Lebanon receiving hospital services. The targets are calculated based on a 12 per cent hospitalization rate for all population cohorts.36
Output 2.2: Public and private hospital service delivery supported
The sector aims to support public hospitals through the provision of equipment to address shortages and replace old and deteriorated ones, and to establish psychiatric wards in the North, South and Bekaa governorates. Interventions will also include supporting hospital staffing capacity, as well as building the capacity of hospital staff through trainings and follow up (including management of psychiatric emergencies). The sector will encourage training of an equal ratio of female to male staff. In response to the COVID-19 outbreak in refugee settings, the Health sector built on the financial support provided over the years for the hospitals to withstand the increasing pressure and to cover hospitalization fees for Syrian and non-Syrian displaced individuals. Further, it supported and expanded the capacity of hospitals37 to equitably implement free testing and case management for displaced populations. The additional capacity built to support the COVID-19 response can be used in the future for general heath responses in the supported hospitals given the multi-use specification of the support. The Health sector will support public hospitals with fuel distribution to reduce their financial hardship, and it will continue to advocate that support of governmental hospitals be permitted in US dollars rather than in only the Lebanese pound. Additional funding needs to be provided for hospitals to join the World Health Organization’s baby-friendly hospital initiative.38 In terms of data collection and analysis and given the increased rates of neonatal mortality among the displaced population, the sector will work closely with and support the Ministry of Public Health to monitor and analyse the neonatal mortality rates among Lebanese.
Given the current multiple crises and the lack of intensive care unit bed capacity at the hospital level, the Health sector will work in 2020 to elaborate an initiative for an effective home-based treatment linked with the national initiative of the Ministry of Public Health to promote palliative care.
In 2021 the sector will support 15 hospitals to respond to COVID-19 needs and 20 hospitals to join the WHO’s baby- friendly hospital initiative.
The risks associated with the outputs under Outcome 2 are both institutional and individual. At the institutional level, public and private hospitals are facing financial challenges to procure and maintain their medical equipment due to their limited ability to pay in hard
(36) The hospitalization rate does not include health interventions done on an outpatient basis, such as dialysis. (37) UNHCR is expanding and rehabilitating the capacity of public and private hospitals across Lebanon to receive and treat COVID-19 patients free of charge and to avoid competition for care. Support includes beds, intensive care units and equipment installation. (38) WHO, UNICEF (2018), “Protecting, promoting, and supporting breastfeeding in facilities providing maternity and new-born services: The revised Baby-friendly Hospital Initiative,” https://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/.
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currency. Consequently, some have decreased staffing, working hours and have even closed several wards. COVID-19 has further challenged the hospitals, which were obliged to implement strict infection, prevention, and control measures to deal with the outbreak. Three major hospitals in Beirut were severely damaged following the Beirut Port explosions, which has increased the burden on the already overstretched health system. At the individual level, vulnerable populations are unable to access hospital care easily due to the higher costs resulting from currency inflation and countrywide COVID-19 lockdowns and fear of infection. The decreased funding and the consequences of the revised UNHCR referral care standard operating procedure that imposes a higher patient share on displaced Syrian individualsixx39 presents an addition risk.
In 2020 the referral care standard operating procedure was revised again to support both displaced individuals and hospitals, but this was temporary and will not likely be extended to 2021. An additional risk is the lack of interest in the support of expensive services, such as dialysis, cancer, thalassemia, haemophilia and others, which will decrease health access and contribute to an increase in morbidity and mortality rates. Health partners can mitigate these risks through advocacy for funding, extended support for public hospital care, reinforced public-private hospitals partnership to cover uninsured populations in private hospitals and increase access to care and strengthened coordination, whereby available funds equitably target the most urgent needs. An additional mitigation measure would be to increase and strengthen preventive primary care, such as vaccinations, antenatal/postnatal care, family planning, and early detection and non-communicable diseases programmes so that complications are prevented and hospital care is not needed.
Outcome 3: Improve outbreak and infectious disease control
Ensuring that Lebanon has in place a national diseases surveillance capacity, with emphasis on early warning alerts and response system (EWARS), is essential considering the numerous challenges that exist. The system helps in estimating the number of children who have dropped out from routine immunization; understanding the potential health risks associated with environmental degradation, such as waterborne diseases; as well as evaluating the impact of poor water, sanitation and hygiene (WASH) conditions in informal settlements. Moreover, it allows the identification of risks associated with acute intoxication by chemicals, pesticides, or bacteria (e.g., food poisoning). The health system should be reinforced in line with the international health regulations’ requirements, especially for cross- border population. Additionally, outbreak preparedness and response should be maintained; and the surveillance unit at the Ministry of Public Health needs to be further strengthened with human resources and information and communication technology to be able to maintain the (39) UNHCR reported a lower admission rate to hospital care in 2019 compared to 2018, and this is believed to be related to the new referral care standard operating procedures (SOPs).
testing, tracing and referral for treatment strategy. The epidemiology surveillance unit will need to be supported for accelerating decentralization of surveillance at the district level. In 2021 the sector is targeting 906 EWARS centres.
Output 3.1: The National Early Warning and Response System (EWARS) expanded and reinforced
The sector will strengthen outbreak control by expanding and building the capacity of the Ministry of Public Health to use the EWARS. This system provides critical data in a timely manner and helps to inform monitoring, planning, and decision-making in any outbreak containment and response. Between 2015 and 2019 support was provided for the development of an information technology platform (DHIS2) established in around 950 health facilities.40 In the surveillance strategic framework and plan of action, support in 2021 will focus on: the harmonization of the health reporting system, the expansion of the national early warning and response system to multidisciplinary stakeholders (such as the Ministry of Agriculture), and the improvement of information flow within the Ministry of Public Health departments and between the Ministry and other concerned stakeholders.41 Further support is needed in terms of data analysis and the decentralization of surveillance and decision-making in terms of public health measures at the district level.
The expansion of the national EWARS and its decentralization will target all primary health care centres within the Ministry of Public Health’s network, laboratories, and hospitals, as well as the epidemiology surveillance unit at the national level. Priorities for 2021 include the reinforcement of 50 existing surveillance sites and the expansion to 100 new sites, in addition to the expansion of COVID-19 testing and tracing capacity and the decentralization of surveillance in the 27 Lebanese districts. To ensure positive outcomes, staffing and logistical support together with IT systems development and equipment is required, as are technical support missions, joint training for surveillance and response teams and close monitoring of the accuracy, timeliness and completeness of reporting.
Output 3.2: Availability of selected contingency supplies ensured
The sector will ensure that a four-month stock of selected contingency vaccines, emergency medications, therapeutic foods, micronutrients, laboratory reagents, response kits, and personal protective equipment for quick and effective response to outbreaks is available and maintained.
Output 3.3: The National Tuberculosis and Acquired Immunodeficiency Syndrome (AIDS) Programmes strengthened (40) Health facilities include primary health care centers, dispensaries, and hospitals. (41) With the advent of COVID-19, additional support was provided in terms of human resources, provision of testing kits and personal protective equipment to the surveillance teams, as well as development of information technology applications for the call centre, the positive cases tracing programme, and other technical support.
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The Health sector will continue supporting the national tuberculosis programme through staffing, capacity- building, procurement of necessary material, the renovation of centres (especially after the Beirut Port explosions) and the procurement of anti-tuberculosis drugs, ancillary medicines, and other consumables. Additional support will be provided to implement infection, prevention, and control measures in the centres to prevent the spread of COVID-19. By implementing these activities, the Health sector will contribute to preventing, identifying, and treating tuberculosis cases in a safe and dignified manner, which will decrease morbidity and mortality rates.
In 2021 the sector is targeting 658 beneficiaries.
As for the national AIDS programme, the sector aims at supporting the development of a protocol for testing, including screening for the Human Immunodeficiency Virus (HIV) and sexually transmitted infections in key population groups, doing confirmatory testing for positive cases, and starting antiretroviral therapy for all HIV cases as soon as diagnosis is confirmed. This will lead to a dramatic reduction in HIV-associated morbidity and mortalityxi and to an increase in life expectancy of patients with HIV infection.
In 2021 the sector is targeting 1,800 patients. In addition, the sector aims to train 65 health care workers on the detection and care for Tuberculosis and HIV.
If support of the Health sector is not maintained under the above-mentioned outputs under Outcome 3, the ability of the country to ensure the continuation of care amid the ongoing crises and to respond to outbreaks will be jeopardized, which could lead to increased outbreaks of vaccine preventable diseases, and in turn to subsequent morbidity and mortality. Hence, the need to: i) maintain the level of support provided to the national surveillance system; ii) increase trust towards public services; iii) strengthen the preventive care system; iv) mainstream COVID-19 prevention; and v) increase outbreak preparedness.
Outcome 4: Improve adolescent and youth health
Investments in adolescent and youth health, in parallel with building the capacity of local institutions, including community centres and schools, is considered an added value to the community that will have lifelong positive effects on both the individuals and the local institutions. Consequently, this outcome will be achieved through the following two outputs.
Output 4.1: School health programme (MoPH/WHO/ MEHE) maintained
The Health sector will continue supporting the Ministry of Education and Higher Education/Ministry of Public Health/WHO’s school health programme, which will be expanded to an additional 25 public and 25 semi- private schools and 25 vocational trainings in 2021. Activities within this programme consist of school health and nutrition education; opportunities for physical education and recreation; and programmes
for counselling, social support, adequate nutrition, and mental health promotion. Maintaining the school health programme will lead to creating a healthier physical and emotional environment for adolescents and youth, and will enhance education outcomes that will lead in the long run to a more productive community. Other activities include the provision of support for the school E-health medical records (procurement of information technology equipment and capacity-building) as well as support for the healthy school environmental project. Support for the school health programme in 2021 will focus on awareness-raising and on ensuring COVID-19 protection and prevention measures.42 Physical distancing techniques and personal hygiene kits will be made available in all public schools. Guidelines for reporting, isolation, quarantine, and case referral at schools will be widely disseminated.
In 2021 the sector is targeting 1,300 schools.
Output 4.2: Access to health care information for the most vulnerable adolescent and youth increased
Marginalized adolescents and youth will be targeted to ensure that health care information reaches out- of-school, street and working children, young people and adolescents through a gender-sensitive approach. Information will include: i) the adoption of awareness materials and outreach methods; ii) strengthened referral of at-risk children and adolescents to case management agencies; iii) promoting other agencies to refer at-risk young people to health care providers; and iv) improving the reach of vaccination through tailored vaccination campaigns and COVID-19 prevention, mental health and sexual and reproductive health activities.
In 2021 the sector is targeting 444,914 adolescent and youth.
Whereas, the turnover may be a risk factor associated with the above-mentioned Output 4.1, identifying and building the capacity of essential staff remains key to sustaining the available services at different levels. The lack of data on out-of-school children, youth, and adolescents is a risk for the programming of Output 4.1. Social stigma is another risk to engage adolescents regarding mental, sexual, and reproductive health issues. A participatory community approach and close coordination with the Protection and Child Protection sectors are needed to increase evidence-based programming and to mitigate the above-mentioned risks. In addition, greater coordination with these sectors is needed to adapt health awareness and information materials and campaign outreach methods to reach working and street children.
In line with the assumptions, associated risks and mitigation measures mentioned at every outcome level, needs prioritization remains vital to ensure a timely response to any funding gap. While the Health sector will aim to ensure that all activities under the strategy are covered, while keeping close coordination
(42) WHO will secure around 50,000 rapid COVId-9 antigen tests, which will allow rapid diagnosis of suspected cases at schools and timely decisions for public health measures.
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and communication with the COVID-19 and Beirut Port explosions responses, priority will be given to increasing equitable and inclusive access of vulnerable population to lifesaving primary and hospital care and to strengthening outbreak prevention and control. In line with LCRP Steering Committee guidance, the Health sector Steering Committee will ensure the alignment of un-earmarked funds to key priorities and underfunded needs of the LCRP. The sector strategy does include different levels of priority needs for various vulnerable groups, but the implementation of activities is conducted based on the most urgent lifesaving ones. Second priority outputs will only be tackled when and if the urgent needs are met. In addition, supplementary research is ongoing43 for increased evidence-based programming and decision-making. This is particularly applicable in the case of developing cost-effective strategies for the provision of subsidized packages of care that are harmonized and complemented to strengthen the national health system.
Identification of sector needs and targets at the individual/households, community and institutional/physical environment level The Health sector calculates the number of displaced Syrian individuals in need based on economic vulnerability, whereby data from the 2020 Vulnerability Assessment of Syrian Refugees in Lebanonxii indicates that 91 per cent of displaced Syrian individuals are living below the poverty line compared to 73 per cent in 2019. The number of displaced Syrian individuals in need and targeted by the sector is 1,365,000.
All 27,700 Palestinian refugees from Syria are considered in need and are targeted by the Health sector. The number of Palestinian refugees from Lebanon considered in need is based on economic vulnerability data indicating that 65 per cent of Palestinian refugees from Lebanon (equal to 117,000) are living below the poverty line. Although 117,000 Palestinian refugees from Lebanon are considered in need, 20,000 are targeted under the LCRP, with the remaining eligible for support through UNRWA.
The sector targets 50 per cent of the Lebanese population in need,44 xiii which is equivalent to about 1,063,000 individuals for general health services (vaccination, medication, etc.) and 12 per cent (123.580) in need of hospital care.45 xiv
It is important to note that there is a wide array of health services provided by actors outside of the LCRP who therefore do not report against the LCRP targets. Solid
(43) The European Union launched a third-party monitoring that will, among other things, analyse current programming. (44) Estimates reveal that more than 55 per cent of the country’s population is now trapped in poverty and struggling for bare necessities. (45) More than half of the Lebanese population (53.3 percent) are not covered by any form of health insurance, or an estimated at 3.86 million individuals.
coordination, consolidation, and exchange of health information are to be strengthened under the LCRP 2021.
Assumptions and Risks In addition to the ones associated with every outcome, assumptions and risks divide into three main areas: funding, equity, and data.
It is assumed that the global community continues to support the Health sector and that support to health system strengthening will increase. There is a risk that weakened global financing for health coupled with the current Lebanese socioeconomic crisis and austerity plan (including the subsidies withdrawal) may weaken the health care system and delay or impede health programming. This, in turn, would further restrict the access of vulnerable populations to primary, secondary and tertiary health care.
It is safe to assume that the Health sector remains determined to equitably expand access to health services and information. There is the risk, however, that the focus is on health access and quality for the broad majority, with insufficient attention to equity. Pressures to support health systems without a strong equity focus could exacerbate inequities in both the supply and demand side of accessibility. A key role will be to draw attention to those ‘left behind’ and the most marginalized and priority groups, and to review systems and policies not only for achieving better averages but to become more inclusive and equitable.
Administrative data systems should be able to track access and health outcomes and point to health system gaps. There is a real risk that the available data do not sufficiently disaggregate, preventing the development of measures to reach and support those left behind. Data may not be available, especially on quality, or may not be sufficiently or systematically used, with limited accountability for results. Support for the strengthening of health data systems is required, including staffing and technical support at the national and local level. This includes support for more disaggregation of data – including information on people with specific needs.
Partnerships Effective partnerships are essential for advancing health equity by making it a shared vision and value, increasing the community’s capacity to shape outcomes, and fostering multisector collaboration. Under the leadership of the Ministry of Public Health, WHO and UNHCR co-lead the Health sector under the Lebanon Crisis Response Plan. Many different stakeholders, including donors and international and national non-governmental organizations, participate in financing and implementing the Health sector strategy. These include organizations with a health mission, such as public health agencies, hospitals, or qualified health centres.
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The Health sector will also closely work with all sector partners by conducting systematic sector working groups, bilateral consultations, and field visits. The sector remains committed to meet on a monthly basis for a comprehensive unified central health working group, to share all needed decisions and guidance with partners, and to monitoring the sector’s outcomes and indicators. Core group meetings will be conducted on a trimester and ad-hoc basis when needed to follow up on the situation and make strategic sector decisions. Service mapping segregated by outcome and output will be updated on a routine basis to prevent duplication of activities and to advise on programmatic gaps. In addition to new ways to bring cross-sector partners together across levels, new forums will likely emerge. Innovative approaches to fostering multisector collaboration to achieve health equity will require participation from many partners. Research on cross-sectoral initiatives will focus on how to strengthen cross-sectoral collaboration. The Health sector will closely work with other sectors – notably Social Stability, Protection, Child Protection, and WASH – to mitigate risks and mainstream notions of conflict sensitivity, gender, youth, persons with specific needs, and environment.
Mainstreaming of accountability to affected populations, protection, conflict sensitivity, age and gender, youth, persons with specific needs, and environment The Health sector’s strategy aims at mainstreaming accountability to affected populations, protection, conflict sensitivity, age and gender, youth, persons with specific needs, and environment throughout all planned activities.
Accountability to affected populations & protection In 2021 the sector will maintain efforts to strengthen the mainstreaming of the core protection principles: meaningful access without discrimination, safety, dignity, and do-no-harm, accountability, and participation and empowerment.
In 2019 the sector conducted a protection risk analysis in each regional field office to identify protection risks and barriers faced by different age, gender and diversity groups in accessing quality and accountable health care. Mitigation measures to address these barriers, including sexual exploitation and the risk of abuse, have been designed and will continue to be implemented by the sector in 2021. To fulfil these commitments, the Health sector will work closely with the Protection, Child Protection, and Sexual and Gender-Based Violence sectors over the course of 2021.
The Health sector will review and adapt the inter-agency minimum standard for referrals and will train health care staff to ensure they are aware of these steps and what they are accountable for. The sector will also work on the establishment of a reporting system for partners to report and track referrals conducted to other service providers, and will make sure to update the health service mapping as well as to share other sectors service mapping with the health care providers.
Conflict sensitivity The sector recognizes that the pressure on health care institutions caused by the increased demand for services is a potential source of conflict. In addition, the differences in out-of-pocket expenses for primary health care between vulnerable Lebanese and displaced Syrian individuals remain a source of tension. To address this, efforts are geared towards balancing the targeting among all population cohorts while increasing the support to vulnerable Lebanese individuals and strengthening the Ministry of Public Health nationally and regionally, as well as the primary health care system overall. This includes the ability of the Ministry of Social Affairs’ social development centres to deal with the increased burden on the system and to ensure continued access for vulnerable Lebanese. The sector will aim at sharing information about the balanced support and the available services. Trainings for partners on conflict sensitivity and the ‘do no harm’ principle will also be considered.
Age and gender Special attention will be paid by the Health sector to children under five years of age, pregnant and lactating women, adolescents (including adolescent girls married before the age of 18), youth, persons with disabilities, older persons, survivors of gender-based violence, persons living with HIV, persons facing gender-based discrimination and other vulnerable groups. Acceptability barriers will also be tackled, including social stigma issues related to gynaecologic health seeking behaviour among adolescent girls. The sector will aim for a female gynaecologist to be available in each health facility.
Pregnant women often cannot pay for their deliveries, which can lead to their babies being retained in incubators and not returned to the mother until the bill is paid. In addition, pregnant women are not fast tracked for delivery appointments at hospitals, which is a barrier to a safe and dignified delivery. Mothers are often unfamiliar with the hospital system and call for appointments late. This means there are often no available delivery spaces, and the mother gives birth at home with an uncertified midwife, which puts the female at risk if there are birth complications. It also means that the newborn does not have a birth notification and so the birth cannot be registered at the personal status department.
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Youth The 2017–2021 Health sector strategy aims to contribute to improvements in youth health (14–25 years), recognizing that the age 20–24 year bracket has a considerably higher percentage of women.xv The sector will target youth by promoting healthy practices through outreach activities at primary health care centres. Alcohol and tobacco use, lack of physical activity, unprotected sex and/or exposure to violence can jeopardize youth health and have long- term consequences. The 2016 Global Health School Surveys reported high rates of substance use (tobacco and alcohol) and mental health conditions (bullying, suicide ideation) among youth.xvi The sector will also target youth through public schools and community centres adhering to the School Health Programme. The access of street and working children and of adolescent girls and boys to health care, as well as their knowledge of health issues will be increased through targeted awareness sessions and inclusive health programming, including through out-of-school vaccination campaigns in coordination with the Education, Protection and Child Protection sectors.
Persons with specific needs Many of the Ministry of Public Health’s primary health care centres and dispensaries are currently not accessible to persons with physical disabilities. This is gradually being addressed by the accreditation process. Moreover, in several health care centres, financial
support/subsidies to cover the cost of laboratory and diagnostics tests is provided to people with disabilities. Specialized organizations also provide physical therapy to people with disability in addition to rehabilitative support, prosthetic and orthotic devices, hearing aids, and eyeglasses.
Environment Lack of safe water, poor wastewater management, solid and medical waste management, poor hygiene and living conditions, and unsafe food all influence the incidence and spread of communicable and non- communicable diseases. Lebanon has been struggling with a national waste management crisis since 2015. This is dealt with by the multidisciplinary national committee for waste management in coordination primarily with the WASH sector. In addition, in 2020 Lebanon was faced with exceptional environmental hazards following several bush fires and the chemical nature of the Beirut Port explosions. The Health sector strategy focuses on providing technical advice and disseminating information to the public on safe practices. Additionally, it emphasizes supporting the Ministry of Public Health to minimize and manage medical waste at the primary health care and hospital level and to strengthen disease surveillance systems to contribute to improved outbreak control. The sector commits to adhering to procedures of the Environmental Marker for the LCRP when implementing activities that might have any negative environmental risks.
Endnotes i. WHO (2020), “Beirut blast: WHO warns dozens of health facilities ‘non-functional’.” ii. Lebanon, Ministry of Public Health (2016), Health Response Strategy, http://www.moph.gov.lb/en/Pages/9/3447/
health-response-strategy. iii. Lebanon, Inter-Agency (2020), “Minimum Standards on Complaints & Feedback for the Lebanon Crisis Response Plan,
https://data2.unhcr.org/en/documents/details/79144. iv. Dr. Seth Berkley (13 October 2020), “The Gavi COVAX AMC explained,” https://www.gavi.org/vaccineswork/gavi-covax-
amc-explained. v. Standard Operating Procedures for Infant and Young Child Feeding in Emergency in Lebanon (3 September 2020),
https://drive.google.com/drive/folders/1Kh9ziBIEQCbAsY-nYBnqEXMvDFK4LxB0 vi. WHO, UNICEF (2018), “Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn
services: The revised Baby-friendly Hospital Initiative,” https://www.who.int/nutrition/publications/infantfeeding/bfhi- implementation/en/.
vii. UNHCR, UNICEF, WFP, WHO (2020), “Infant and Young Child Feeding in the Context of the COVID-19 Pandemic Eastern, Central and Southern Africa,” https://drive.google.com/drive/folders/1NY02GvpZY4TqwJsHaqNWR9MZfScdhltT.
viii. UNHCR (2019), Referral Care SOPs. ix. UNHCR (2018), Referral Care SOPs. x. x. Centers for Disease Control (CDC) (2017), “Benefits and Risks of Antiretroviral Therapy.” xi. UNHCR, UNICEF, WFP (2020), “Vulnerability Assessment of Syrian Refugees in Lebanon 2020.” xii. ESCWA (2020), “ESCWA warns: More than half of Lebanon’s population trapped in poverty,” https://www.unescwa.org/
news/Lebanon-poverty-2020. xiii. Social Watch (2020), “Gaps and Efforts in Social Protection,”https://www.socialwatch.org/node/11031. xiv. UNHCR, UNICEF, WFP (2016), “Vulnerability Assessment of Syrian Refugees in Lebanon 2016.” xv. Lebanon, Ministry of Education and Higher Education, Ministry of Public Health, CDC, WHO (2016), Lebanon 2016 Global
School-based Student Health Survey.
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Roukaya going to the Ministry of Public Health’s Primary Health Care Center in Aranissa with her two children during the COVID-19 pandemic. Photo Credit: Premiere Urgence Internationale, 07/2020.
Total sector needs and targets in 2021
Population Cohorts
Total Population
Total Population
in Need
Total Population
Adolescent
(10-17)
Lebanese 3,864,296 1,500,000 1,062,681 552,594 510,087 52% 48% 331,025 31% 173,642 16.3% 7,016 2.0%
2.0%
2.0%
2.0%
663,390 51% 49% 723,450 53%
263,445 19,3% 106,800
Palestinian Refugees from Syria
27,700 27,700 27,700 14,349 13,351 52% 48% 11,171 40% 4,770 17.2% 3,451
Palestinian Refugees from Lebanon
180,000 117,000 20,000 9,920 10,080 50% 50% 6,956 35% 3,056 15.3% 5,199
GRAND TOTAL 5,571,996
MoPH
MEHE/Schools
MoPH/PHC
Add additional
% additional disaggrega-
Displaced Syrians Palestinian Refugees from Syria (PRS)
Palestinian Refugees from Lebanon (PRL)Lebanese
Displaced Syrians Palestinian Refugees from Syria (PRS)
Palestinian Refugees from Lebanon (PRL)Lebanese
Outcome 1: Improve access to comprehensive primary healthcare (PHC)
Indicator 1A Description Means of Verification Unit Frequency
Percentage of displaced Syrians, vulnerable Lebanese, Palestinian Refugees from Syria (PRS) and Palestinian Refugees from Lebanon (PRL) accessing primary healthcare services.
Number of displaced Syrians, vulnerable Lebanese, Palestinian Refugees from Syria (PRS) and Palestinian Refugees from Lebanon (PRL) accessing primary healthcare services out of those who report needing primary healthcare services
Vulnerability Assessment of Syrian Refugees (VASyR) UNHCR Health Access and Utilization Survey (HAUS) Ministry of Public Health (MoPH) Health Information System (HIS) UNRWA Assessments UNRWA Health Information System
Percentage Yearly
Indicator 1B Description Means of Verification Unit Frequency
Percentage of vaccination coverage among children under 5 residing in Lebanon
MoPH/WHO Expanded Programme on Immunization (EPI) Cluster survey
Yearly
100% 89% 90%90% 90%N/A N/A 90%N/A
Baseline Result 2019 Target 2021
100%
100%
100%
100%N/A N/A N/A N/AN/A N/A N/AN/A
Baseline Result 2019 Target 2021
100%
100%
100%
Percentage"Percentage of infants who received: - The 1st (DTP1) / 3rd (DTP3) dose, respectively, of diphtheria and tetanus toxoid with pertussis containing vaccine - The 3rd dose of polio (Pol3) containing vaccine. May be either oral or inactivated polio vaccine. - One dose of inactivated polio vaccine (IPV1) - The 1st dose of measles containing vaccine (MCV1) - The 2nd dose of measles containing vaccine (MCV2) - The 1st dose of rubella containing vaccine (RCV1) - The 3rd dose of hepatitis B containing vaccine following the birth dose. (HepB3) - The 3rd dose of Hemophilus influenza type b containing vaccine. (Hib3) Percentage of births which received: - A dose of hepatitis B vaccine (HepB) within 24 hours of delivery (Source: WHO and UNICEF estimates of national immunization coverage - July 4, 2017)"
Sector Logframe
126
Institutions
Total
Indicator 3A Description Means of Verification Unit Frequency
"The sector aims to contribute to strengthening outbreak control through building the capacity of the MoPH in surveillance and response. The focus will be on public health Early Warning and Response System strengthening and expansion
Functional EWARS centers are those that report through the EWARS system Baseline: 50 Target: 396 "
Number of functional EWARS centers
MoV: - MoPH periodical bulletins and alerts on website - MoPH list of EWARS functional centers every 6 months Responsibility: MoPH, WHO

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